Forms & Insurance

Forms

To help ensure quick service, we ask you to please print out a copy of these forms, fill them out, and bring them in to the office.

New Patient Forms

Acknowledgement of Privacy Notification

Insurances

AARP
Aetna
AEG
American Republic Insurance Company
Anthem Blue Cross
Anthem Blue Cross Blue Shield

In-Network Insurances

  • AARP
    • AARP Medicare Advantage POS
    • AARP Medicare Advantage PPO
    • AARP Medicare Complete (HMO)
    • AARP Medicare Supplement
    • AARP MedicareComplete Choice (PPO)
    • AARP MedicareComplete Plus (HMO-POS)
    • AARP Personal Health Insurance Plan
  • Aetna
    • Aetna Choice POS II (Aetna HealthFund)
    • Aetna Choice POS II on the Altius Network
    • Aetna Choice® POS (Open Access)
    • Aetna Choice® POS II (Open Access)
    • Aetna Health Network Only (Open Access)
    • Aetna Health Network Option (Open Access)
    • Aetna HealthFund HMO (available in CA only)
    • Aetna HealthFund® Aetna Health Network Only (Open Access)
    • Aetna HealthFund® Aetna Health Network Option (Open Access)
    • Aetna Select
    • Aetna Value Network HMO (available in CA and NV only)
    • CA Medicare HMO Orange/San Bernadino/Losa Angeled CA Prime Plan
    • Elect Choice EPO (Open Access) on the Altius Network
    • HMO
    • HMO (Open Access)
    • HMO Deductible Plan (CA members only)
    • Managed Choice (Open Access)
    • Managed Choice (Open Access) on the Altius Network
    • Managed Choice POS
    • Medicare Open (Private Fee-for-Service)
    • Medicare Plan (PPO)
    • Open Access Aetna Select (Aetna Health Fund)
    • Open Access Elect Choice EPO (Aetna Health Fund)
    • Open Access Managed Choice POS (Aetna Health Fund)
    • Open Choice PPO
    • Open Choice® PPO (Aetna Health Fund)
    • PCP Referral Plan (TX only)
    • Workers' Comp Access
  • AIG
    • AIG Personal Health Insurance
  • American Republic Insurance Company
    • PHCS PPO
  • Anthem Blue Cross
    • Blue Cross PPO (Prudent Buyer)
    • Lumenos Plans (PPO)
    • PPO Share
    • Premier Plus PPO
  • Anthem Blue Cross Blue Shield
    • Access Blue
    • Blue Access Choice (PPO) (Missouri)
    • Blue Access Network (Indiana)
    • Blue Access PPO
    • Blue Cross PPO (Prudent Buyer)
    • Health Choice (Health Choice PPO)
    • National PPO (BlueCard PPO)
    • PPO (Colorado)
    • PPO (Connecticut)
    • PPO (Nevada)
    • PPO/EPO
    • Preferred Blue
    • Preferred Blue for PPO (New Hampshire)
    • Premier (Connecticut)
  • Arkansas Blue Cross Blue Shield
    • Arkansas FirstSource PPO
    • Blue Select (PPP)
    • Blue Solution PPO
    • BlueCare PPO
    • Comprehensive Blue PPO
    • HSA Blue PPO
    • True Blue PPO
  • Beech Street
    • Complementary
    • Limited Benefit Plan
    • Primary
  • Blue Cross Blue Shield
    • BlueCard PPO Basic
    • BlueCard PPO/EPO
    • BlueCard Traditional
    • Federal Employee Program - Basic Option
  • Blue Cross Blue Shield Federal Employee Program
    • Basic
  • Blue Cross Blue Shield of Arizona
    • Acclaim PPO/EPO
    • Indemnity
    • PPO/EPO Statewide
    • Secure HMO Network
  • Blue Cross Blue Shield of Florida (Florida Blue)
    • BlueOptions
  • Blue Cross Blue Shield of Georgia
    • Blue Choice PPO
    • BlueChoice Preferred Provider Organization (PPO)
  • Blue Cross Blue Shield of Illinois
    • BasicBlue PPO
    • Participating Provider Organization [PPO]
  • Blue Cross Blue Shield of Kansas
    • AffordaBlue
    • Blue & U Classic (Copay)
    • Blue & U First
    • Blue Choice
    • Traditional
  • Blue Cross Blue Shield of Kansas City
    • BlueAccess
    • BlueCard Traditional
    • Preferred-Care Blue
  • Blue Cross Blue Shield of Louisiana
    • BlueMAX
    • BlueSaver
  • Blue Cross Blue Shield of Massachusetts
    • Blue Precision/PPO Blue Options v.4
    • Preferred Blue PPO
    • Preferred Blue PPO Options v.4
  • Blue Cross Blue Shield of Michigan
    • Community Blue/Blue Preferred Plus PPO
    • Michigan Conference of Teamsters Welfare Fund (MCTWF) PPO
    • MIChild
    • MPSERS
    • PPO Plans - Group Enrollees
    • Traditional - Group Enrollees
  • Blue Cross Blue Shield of Minnesota
    • Allina Health Network (Blue Plus)
    • Blue Access Choice
  • Blue Cross Blue Shield of Nebraska
    • Beatrice BlueChoice
    • Boone County BlueChoice
    • Methodist BlueChoice
  • Blue Cross Blue Shield of New Mexico
    • Blue Transitions (EPO)
    • BlueDirect (PPO)
    • BlueNet EPO
    • Preferred Provider Organization (PPO)
  • Blue Cross Blue Shield of North Carolina
    • Blue Options
  • Blue Cross Blue Shield of Rhode Island
    • BlueSolutions
    • Bryant University Healthplan
    • HealthMate Coast-to-Coast
    • VantageBlue
  • Blue Cross Blue Shield of South Carolina
    • Preferred Blue - PPO
  • Blue Cross Blue Shield of Texas
    • Blue Advantage Bronze HMO
    • Blue Advantage Platinum HMO
    • Blue Advantage Silver HMO
    • Blue Choice Silver PPO
    • BlueChoice PPO Plan
    • BlueOptions
    • EPO
    • HMO Blue Texas
    • UT Select PPO
  • Blue Cross Blue Shield of Vermont
    • BCBSVT Network Providers
    • New England Health Plan
  • Blue Cross Blue Shield of Wyoming
    • Participating Provider (PPO)
  • Blue Cross of Idaho
    • Connected Care (East)
    • PPO
  • Blue Cross of Northeastern Pennsylvania
    • AffordaBlue
    • BlueCare EPO
    • BlueCare PPO
    • BlueCare QHD EPO
    • BlueCare QHD PPO
  • Blue Shield of California
    • Active Choice Plans
    • Base PPO 30
    • Blue Shield of California PPO Network
    • Point of Service (POS)
    • Premier PPO 15
    • Shield Spectrum PPO 750 - 80/60
    • Trio ACO HMO
  • Blue Shield of Northeastern New York
    • EPO
    • PPO
  • Capital Blue Cross
    • PPO
    • PPO Choice 1
    • PPO Choice 2
  • Care Improvement Plus
    • Medicare Advantage
  • CareFirst Blue Cross Blue Shield
    • BlueChoice Advantage
    • BluePreferred
    • HealthyBlue Advantage
    • Preferred Provider Organization (PPO)
  • Caterpillar
    • UHC Choice Plan
    • UHC PPO Network Plan
  • CBA Blue
    • BlueCard PPO
  • Cigna
    • Choice Fund PPO
    • EPO
    • HMO
    • HMO Open Access
    • Medicare Access
    • Network Open Access
    • Open Access (all deductible levels)
    • Open Access Plan
    • Open Access Plus
    • Open Access Plus/CareLink
    • Open Access Value (all deductible levels)
    • POS Open Access
    • Workers' Compensation
  • Cigna-HealthSpring
    • HMO
  • Coventry Health Care
    • Coventry National Network
    • First Health
  • Empire Blue Cross Blue Shield
    • Empire EPO Essential
    • Empire PPO
    • Empire Prism EPO
    • Empire Prism PPO
    • PPO
    • Value EPO
  • Florida Blue: Blue Cross Blue Shield of Florida
    • BlueOptions
  • GeoBlue
    • GeoBlue Expat
    • GeoBlue Traveler
  • Health Net
    • AZ HMO CommunityCare Network Small Business
    • CA Elect Open Access
    • CA Elect Open Access - ExcelCare/Silver Network
    • CA HMO - ExcelCare/Silver Network
    • CA HMO - WholeCare Network
    • CA PureCare HSP Small Business
    • CA Salud EPO
    • CA Salud HMO y mas (CaIPERS members only)
    • CA Salud PPO Plus
    • CA Seniority Plus (Employer HMO)
    • CA Seniority Plus Amber I (HMO SNP)
    • CA Seniority Plus Amber II (HMO SNP)
    • CA SHP Healthy Kids HMO
    • CA SHP Medi-Cal
    • Healthy Heart Plan 1 (HMO)
    • National PPO - First Health
    • Options Plus - Violet (PPO)
    • OR Violet Option 3 (Medicare PPO)
    • PPO & PPO Plus
    • Premier Network
    • Primary EPO
    • Salud EPO/PPO
    • Salud HMO Plus
    • Salud HMO y mas
  • HealthFirst (NY)
    • Healthfirst Bronze Leaf Premier
    • Healthfirst Child Health Plus
    • Healthfirst Coordinated Benefits Plan (HMO)
    • Healthfirst Healthy NY
    • Healthfirst Healthy NY Small Group
    • Healthfirst HMO A-VAD, HMO B-VAD, HMO C-VAD, and HMO D-CAD
    • Healthfirst Life Improvement Plan (HMO SNP)
  • HealthSmart
    • C-8 (PFOA) Medical Monitoring Program
    • CompNET
    • HealthSmart ACCEL
    • HealthSmart Auto Medical
    • HealthSmart National
    • HealthSmart Payors Organization (HPO)
    • HealthSmart Preferred Care
    • Workers Compensation Network
  • HighMark Blue Cross Blue Shield
    • BCBS PPO
    • PPOBlue
  • Highmark Blue Cross Blue Shield of Delaware
    • BCBS EPO
    • BCBS PPO
    • PPO
    • PPO Blue Total Health
  • HighMark Blue Shield
    • PPOBlue
  • Horizon Blue Cross Blue Shield of New Jersey
    • Federal Employee Plan - Basic Option
    • Horizon Advantage EPO (with BlueCard PPO)
    • Horizon PPO
  • Independence Blue Cross
    • National BlueCard PPO
    • Personal Choice PPO
  • Medicare
    • Medicare
  • Memorial Hermann
    • PHCS
  • Moda Health
    • PHCS
  • Multiplan PHCS
    • PHCS
    • PHCS Healthy Directions or Extended PPO
  • Palmetto GBA (Railroad Medicare)
    • Railroad Medicare
  • POMCO
    • POMCO-PHCS/Multiplan
  • Premera Blue Cross
    • AK Global with BlueCard PPO/Traditional
    • AK HeritagePlus with BlueCard PPO/Traditional
    • AK HeritageSelect with BlueCard PPO/Traditional
    • Foundation & Foundation Plus 1 with BlueCard PPO/Traditional
    • Global with BlueCard PPO/Traditional
    • Heritage & Heritage Plus 1 with BlueCard PPO/Traditional
    • Heritage Prime with BlueCard PPO/Traditional
    • Heritage Signature with BlueCard PPO/Traditional
    • Premera BlueCard PPO/Traditional Network
  • Regence Blue Cross Blue Shield
    • Oregon Select OHSU
    • Preferred (PPO)
    • RealValue
  • Triple-S Salud: Blue Cross Blue Shield of Puerto Rico
    • Commercial (PPO)
    • Federal
    • Federal BCBS
  • UnitedHealthcare
    • AARP Medicare Advantage POS
    • AARP Medicare Advantage PPO
    • AARP Medicare Complete Choice (PPO)
    • AARP Medicare Complete Plan 1 (HMO)
    • AARP MedicareComplete Mosaic (HMO)
    • AARP MedicareComplete SecureHorizons Essential (HMO)
    • AARP Personal Health Insurance Plan
    • Compass Rose Health Plan FEHP FFS (PPO)
    • Heritage Choice
    • Heritage Choice Standard
    • Heritage Plus/Heritage EPO- Iowa, Illinois and Tennessee
    • Heritage Premier
    • Heritage Select
    • M.D. IPA
    • M.D. IPA Preferred
    • Neighborhood Health Partnership (NHP) - Commercial
    • Neighborhood Health Partnership (NHP) - Mercy Select
    • Northwell Health Employee Plan
    • Optimum Choice HMO
    • Optimum Choice Preferred POS
    • Oxford Medicare Network
    • Pacificare SignatureElite Plus (TX/OK Employers Only)
    • River Valley Choice Plus
    • United Behavioral Health
    • UnitedHealthcare Choice
    • UnitedHealthcare Choice HMO/Choice Plus HMO
    • UnitedHealthcare Choice Plus
    • UnitedHealthcare Choice Plus with Harvard Pilgrim
    • UnitedHealthcare Choice with Harvard Pilgrim
    • UnitedHealthcare Compass HMO/ Compass Balanced HMO/Compass Plus HMO
    • UnitedHealthcare Compass Plus
    • UnitedHealthcare Compass/ Compass Balanced
    • UnitedHealthcare Core
    • UnitedHealthcare Dual Advantage
    • UnitedHealthcare Dual Complete (HMO SNP)
    • UnitedHealthcare MedicareComplete Choice
    • UnitedHealthcare MedicareComplete Choice Essential (regional PPO)
    • UnitedHealthcare MedicareComplete Focus (HMO)
    • UnitedHealthcare MedicareDirect Essential (PFFS)
    • UnitedHealthcare Navigate
    • UnitedHealthcare Navigate Plus
    • UnitedHealthcare Navigate/Navigate Balanced
    • UnitedHealthcare Options PPO
    • UnitedHealthcare Options PPO with Harvard Pilgrim
    • UnitedHealthcare Passport Connect Choice
    • UnitedHealthcare Passport Connect Choice Plus
    • UnitedHealthcare Passport Connect Options PPO
    • UnitedHealthcare Select EPO
    • UnitedHealthcare Select HMO
    • UnitedHealthcare Select Plus HMO
    • UnitedHealthcare Select Plus POS
    • UnitedHealthcare SignatureValue (HMO)
    • UnitedHealthcare SignatureValue Advantage (HMO Value Network)
    • UnitedHealthOne
    • Vision
  • UnitedHealthcare Community Plan
    • TX: Care Improvement Plus Dual Advantage (Local PPO SNP)
  • UnitedHealthOne
    • UnitedHealth Allies
    • UnitedHealthcare Choice Plus Network
    • UnitedHealthcare Vision
  • US Health Group
    • Private Healthcare Systems (PHCS) (PPO)
  • Wellmark Blue Cross Blue Shield
    • Alliance Select (Iowa)
    • Blue Choice (Iowa and Bordering Counties)
    • Blue Rewards POS
    • Blue Select (South Dakota)